Patients with borderline personality disorder (BPD) are often high users of health care and may present with multiple crises and minor incidents of self-harm or threats.1 As with the boy who cried wolf, inpatient consultants and health care providers may end up feeling manipulated and may not take suicide risk very seriously.

CASE VIGNETTE

Ms A, a 22-year-old, was brought to the emergency department (ED) by ambulance; she had overdosed on zolpidem. After detoxification in the ED, a psychiatric consultation was requested. Ms A told the consultant that she had had a bad day and simply took 5 extra zolpidem tablets to “go to sleep” and that “it was just a stupid thing to do.” While obtaining the history, the consultant noted that Ms A’s therapist had left for vacation 2 days earlier.

The consultant informed Ms A that her overdose was just a reaction to her therapist’s vacation, that she did not have a major mental disorder, and that she was going to be discharged. In response, Ms A became irate, “No one cares about me; I just tried to kill myself and you just want to get rid of me! If you don’t admit me, I’m going to walk in front of the next bus!”

Feeling manipulated but with no other options, the consultant admitted Ms A to the inpatient psychiatric unit. Once there, the staff noted that Ms A seemed cheerful, childlike, and cooperative. In the morning, however, Ms A angrily demanded to be discharged when she was refused a smoking pass. The inpatient psychiatrist questioned Ms A about the recent overdose and suicide threats; she stated that she never intended to carry out her threats but was just trying to get attention.

Although health care providers may not take the threat of suicide seriously in patients who have BPD, these patients are often serious about suicide. Long-term studies indicate that compared with controls, patients with BPD have an 8% to 10% increased risk of completed suicide, which is comparable to that of patients who have MDD and schizophrenia.2 Moreover, minor overdoses frequently represent ambivalent suicide intent, and episodes of non-suicidal self-injury are markers for suicide risk and predict future suicide attempts.3,4

Conscious “attention-seeking” behavior is rare, although both patients and health care providers may attempt to frame suicidal behavior that way. As with Ms A, patients may minimize the seriousness of their intent, stating it was just “attention-seeking,” or “I was just trying to sleep,” making it easy for health care providers to question the validity of their patients’ actions.

On the other hand, not every gesture or threat is an indication for a prolonged inpatient hospital stay. Patients may threaten suicide as a way of obtaining or extending hospital stays. A study by Gregory and Jindal5 of 100 consecutive inpatient admissions showed that factitious production of suicide ideation, gestures, and threats was common among women with BPD at the time of discharge. Suicide threats and behavior served as a means of justifying the seriousness of their condition to providers, and to themselves. Given this information, is the underlying message that we should take suicidal ideation and behavior seriously, but not too seriously? How can we understand suicide risk in BPD?

What is already known about suicide risk in patients with borderline personality disorder (BPD)?

What new information does this article provide?

? The article provides a model for understanding suicide risk and behavior in patients with BPD and how that affects clinician-patient interactions.

What are the implications for psychiatrists?

? Minor overdoses or superficial cutting behaviors are not merely attention-seeking, even if the patient says they are. Are patients placing blame on themselves or on others for recent interpersonal difficulties? If you find yourself in conflict with the patient, realize that the patient likely has an internal conflict over the same issue. A good therapeutic alliance includes clear expectations and boundaries, helping patients build autonomous motivation, and helping patients verbalize experiences and emotions.